TLN Questionnaire
Please fill out the form completely.
Name
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First Name
Last Name
Cell Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Birthdate
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Month
-
Day
Year
Date
Height (In)
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Weight (LB)
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Waist (In) - Even with belly button
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Hips (In) - Widest part of the hips and include the glutes
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Please list 3 goals you would like to achieve during this process?
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Do you currently exercise?
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If you currently exercise, what type of exercise are you doing? (Ex. CrossFit, yoga, spin, etc. - Please list all that apply)
How often per week do you workout?
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How long in duration are your training sessions?
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What time of day do you workout?
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How intense are your training sessions on a scale of 1 to 10? (10 being the hardest.)
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How active are you the rest of the day?
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Please give us a description of your dieting history over the last 5-10 years? This will help us have a better understanding of your background and create the best plan for you.
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Do you have any food allergies or sensitivities? If so, please explain.
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Any preexisting medical conditions that we should be aware of? (Hypothyroid, Hashimotos, Type II Diabetes) If so, please explain.
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Are you currently taking any medications that we need to be aware of? If so, please explain.
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Have you ever counted macros/flexible dieted before?
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Have you ever used My Fitness Pal before?
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How did you hear about us?
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Are you ready for this?
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I am aware that I should consult with a doctor before starting nutrition coaching. I also understand that at The Life Nutrition we are not nutritionist but we have helped many people reach their goals.
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Yes
No
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